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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606472
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:19:58 PM


Document Has Been Signed on 01/27/2023 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:BANNER RIDGE COUNTRY HOMEFACILITY NUMBER:
197606472
ADMINISTRATOR:ELNA C. VILLAFLORFACILITY TYPE:
740
ADDRESS:1006 BANNER RIDGE ROADTELEPHONE:
(909) 240-1899
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 5DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Elena Villaflor, AdministratorTIME COMPLETED:
03:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced required 1 year visit. LPA met with staff Raquel Salen and stated the purpose of the visit. LPA later met with Administrator, Elna Villaflor and stated the purpose of the visit. LPA conducted annual using the Infection Control Domain. LPA was screened upon entry.

The facility is licensed to serve 6 non-ambulatory residents aged 60 and above. Hospice waiver for 1. The facility is a one story residential home with 5 bedrooms, 2 full bathrooms, living room, formal and informal dining room, kitchen, family room, laundry room, garage, front and back yards and a nook in kitchen area.

The last fire/emergency drill was conducted on 12/28/2002. Administrator certificate expires 6/05/2024.

OBSERVATIONS:

· The interior and exterior physical plant was inspected. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.


· COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
· Facility has designated a COVID-19 isolation room if needed.
· A posted Emergency Disaster Plan was observed.
· Centrally stored medications/30-day supply of medications were reviewed.
· Staff were observed wearing mask. Clients do not wear masks be adhering to social distancing guidelines .
· The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
· Water temperature was not within regulatory range. It measured 123.1 degrees in bathroom.
· Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
· The facility submitted a COVID-19 Mitigation Plan. An Infection Control Plan (ICP) has been submitted.
Deficiencies were cited. Please see 809D for details.

Exit interview was conducted with Administrator, Elna Villaflor. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2023 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BANNER RIDGE COUNTRY HOME
FACILITY NUMBER: 197606472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Bathroom counter has a broken door, kitchen drawer is in need of repair and floor under the supply cabinet needs to be repaired or replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Administrator will make all repairs and send proof to LPA by POC date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water in bathroom measured 123.1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2023
Plan of Correction
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Administrator adjusted the water temperature and it is now within regulatory range. ****NO FURTHER ACTION IS REQUIRED****
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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